Reoperative arch-first total arch repair after previous acute type A aortic dissection repair.

Objective: We sought to review the outcomes of our arch-first total aortic arch repair (TAR) using a trifurcated graft after previous acute type A aortic dissection (ATAD) repair. Methods: From February 2006 to June 2024, 62 patients underwent reoperative TAR after ATAD repair. The first-stage TAR includes axillary artery cannulation, minimal dissection without aortic crossclamping, myocardial protection using systemic potassium and retrograde blood cardioplegia, an arch-first technique with deep hypothermia (20 °C), and construction of a classical elephant trunk through a partial transverse incision distally or proximally to old distal aortic anastomosis. Results: The median age at reoperative TAR was 63.5 years. The median interval from initial ATAD repair to reoperative TAR was 3 years. A concomitant procedure was performed in 20 patients (32.3%). The median cardiopulmonary bypass and lower body circulatory arrest times were 227.5 and 97 minutes, respectively. Operative mortality was 1.6% (n = 1/62), as was the incidence of stroke (1.6%) and renal-replacement therapy (3.2%). Stage II repair was performed or planned in 49 patients (open repair [above the celiac axis in most patients], n = 42; endovascular, n = 3; endovascular converted to open repair, n = 2; and waiting for repair, n = 2). Median interval between staged procedures was 63 days [interquartile range, 36, 134]. Mortality of stage II procedure was 4.3% (n = 2/47) with no spinal cord injury. Kaplan-Meier analysis showed that estimated survival at 5 years was 82.7 ± 6.7%. Conclusions: Our reoperative TAR is safe in the setting of residual dissection that minimizes dissection of the cardiac structures, simplifies the distal anastomosis, and protects vital organs.